Laparoscopic surgery effective in chronic pancreatitis

Last Updated: 2017-03-01

By David Douglas

NEW YORK (Reuters Health) - Laparoscopic total pancreatectomy with islet autotransplantation and intraoperative islet separation reduces hospital length of stay and may curb opioid dependence in selected patients with chronic pancreatitis, according to a small case series.

In fact, Dr. Martin A. Makary told Reuters Health by email, "The operation represents a milestone for minimally-invasive surgery technology, where multiple organs can be operated upon through a band-aid size incision."

As reported February 22 online in JAMA Surgery, Dr. Makary of Johns Hopkins University, Baltimore and colleagues theorized that a totally laparoscopic approach would offer advantages over open surgery. It would also avoid "the high costs and consumption of operating room resources associated with robotic-assisted surgery."

They undertook laparoscopic procedures in 22 patients, including two who required conversion to open surgery because of difficult anatomy and previous surgery. Indications included genetic mutation, idiopathic pancreatitis and alcohol abuse.

Mean operative time was 493 minutes, considerably less than the 637 minutes reported in a previous series of patients undergoing the open approach. This was also the case versus another open series and compared to the 712 minutes seen with a robotic approach.

Regardless of the approach, several hours of operative time were required to process the islet cells for autotransplantation. In this series, the islet isolation laboratory was set up in the operating room, say the investigators, which brought mean islet isolation time down to 185 minutes, substantially less than in studies using other approaches.

"Minimizing islet isolation time," the researchers note, "increases islet count and viability, which is positively correlated with insulin independence."

"Our glycemic outcomes were similar to 1-year insulin independence rates reported in the literature," the researchers say.

At a median follow-up of 12.5 months, five patients were insulin independent, nine patients required 1 to 10 U/d of basal insulin, five required 11 to 20 U/d, and the remaining patients required more.

Mean hospital stay was 11 days, again less than the 12.6- to 16-day stays reported in other studies. The all-cause 30-day readmission rate was 35%. No patients died and none had postoperative wound infection, hernia, or small-bowel obstruction.

At a median follow-up of six months, 18 patients had a decrease or complete resolution of pain, and 12 no longer required opioid therapy.

"Given the endemic problem of opiate use," Dr. Makary concluded, "the minimally-invasive operation enables patients with chronic pain from pancreatitis to have less pain while lowering the risk of diabetes after removing the pancreas."

In an editorial, Dr. Chirag S. Desai of the University of North Carolina, Chapel Hill, and Dr. Khalid M. Khan of Georgetown University Hospital, Washington, DC, say the approach "appears to benefit patients and represents a natural extension to the standard surgical procedure."

"The main benefit of the technique," they observe, "is to reduce postoperative pain, and the procedure offers advantages, as with any laparoscopic procedure, over an open abdominal procedure."

In email to Reuters Health, Dr. Desai added, "Autologous islet cell transplant after total pancreatectomy is a very good option for the select patients with chronic or recurrent pancreatitis," offering advantages beyond those "often calibrated only by insulin independence rate post-surgery by critics."

Also, Dr. Desai said, "The importance of doing islet isolation in the clean room facility in compliance with GMP (good manufacturing practice) should not be under-appreciated."

SOURCE: http://bit.ly/2lz6oxO and http://bit.ly/2mtA9nI

JAMA Surg 2017.